Provider Demographics
NPI:1679835946
Name:DMITRY KHASAK MD PC INC
Entity Type:Organization
Organization Name:DMITRY KHASAK MD PC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERLANTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-889-7047
Mailing Address - Street 1:100 PAVONIA AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-2778
Mailing Address - Country:US
Mailing Address - Phone:201-626-4040
Mailing Address - Fax:866-861-0767
Practice Address - Street 1:100 PAVONIA AVE STE 409
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-2778
Practice Address - Country:US
Practice Address - Phone:201-626-4040
Practice Address - Fax:866-861-0767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty